Employee Staff Screening Questionnaire – USC Administrative Operations

Your safety is our priority. We are screening all employees for signs of virus. Please answer the questions below, provide your name and date. Thank you!

In the past 14 days have you:

EMPLOYEE STAFF SCREENING QUESTIONNAIRE

Had close contact with a person known to have the novel coronavirus (COVID-19)? *

Yes

Do you have cold or flu-like symptoms: fever, runny nose, sore throat, coughing, difficulty breathing, mild diarrhea? *

Yes

Have you been tested for COVID-19? *

Yes

If yes, what was the result? *

Have you been diagnosed with COVID-19? *

Yes

First Name *

Last Name *

Department * Department

Email *

Office Phone Number *

Mobile Phone Number

reCAPTCHA

If you are human, leave this field blank.

Employees responding Yes to either question should:
1. Return home.
2. Contact Employee Health services at USC Student Health at 213-740-9355 (WELL) to arrange for screening and clearance to return to work.
3. Contact their personal physician if they feel they need medical attention.

By Order of the County of Los Angeles Department of Public Health Health Officer employers must:
– Direct all employees to stay home while sick.
– Conduct symptom checks on all employees before entering the workspace.